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10/10/2018

ODM Weighs in on Vent Rules and Hospice

LeadingAge Ohio sought clarification from Ohio Department of Medicaid (ODM) staff regarding the Ohio Department of Medicaid rule 5160-3-18 Nursing facilities (NFs) ventilator program and how it might pertain to a terminal wean and/or palliative ventilator withdrawal for a terminal patient. Hospice/palliative care providers had questions with regards to the applicability of the rule for hospice vent patients in a NF.

ODM had provided previous clarification for how a nursing facility and hospice should handle a ventilator-dependent hospice individual. The nursing facility is to notify the hospice agency that they will bill the hospice in accordance with agreed-upon contracted ?? which is usually 95% or 100% of the facility rate. For example, as of January 1, 2019, nursing facilities would bill either $754.22 (100% of rate) or $716.51 (95% of rate) based on their contract.  The hospice, as the pass through, will only be able to bill Medicaid 95% of the rate.

Ms. Guyman insert title, noted that with regards to the ventilator rule, ODM was not overly prescriptive to ensure that the patient/family voice and goals of care and the clinical expertise of the team are the focus of how decisions are made. The rule allows nursing facilities that are participating in the ventilator program to determine if they would allow weaning services for a patient who would like to have a ventilator discontinued. If a facility allows ventilator weaning services, there is increased reimbursement for the additional care needs of this type of patient. Requirements include:

  • Establishment of ventilator weaning protocol by a physician who is trained in pulmonary medicine and available via phone 24/7 while the ventilator weaning services are provided.
  • Retention of a respiratory care professional trained in basic life support onsite and available to assist the patient a minimum of 8 hours a day and then by phone the remaining 24 hours.
  • Availability of an RN with basic life support training onsite 24/7 while the ventilator weaning services are being provided.

For terminal or palliative care patients, the nursing facility should have policies and procedures in place for a terminal withdrawal of a ventilator. In addition to the protocol, if the facility would like to seek enhanced reimbursement for the terminal withdrawal, the facility would have to have the above-mentioned staff in place to provide the needed support if warranted.  If the facility is not seeking the enhanced reimbursement for the terminal withdraw of the ventilator, then the facility would not have to have a respiratory care professional or RN training in basic life support in the facility or on call for the patient. ODM also provided clarification that most physicians, including hospice and palliative care physicians, are trained in pulmonary medicine, and a facility does not have to have a specialized physician (pulmonologist) write the protocol or available via phone 24/7 for any type of ventilator weaning services.

Hospices providing care of ventilator-dependent hospice patients in a NF or ventilator withdrawal services will need to notify Jill Fleming, to ensure that the relevant claims are overridden in the system to pay the claim accurately.

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